Inspection on 12/06/07 for Anne Residential Home (1)

This inspection was carried out on 12th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Anne Residential Home (1) 22/08/06

Anne Residential Home (1) 31/01/06

Anne Residential Home (1) 25/07/05

Anne Residential Home (1) 04/11/04

Anne Residential Home (1) 09/12/03

Similar services:

Spinney (The)

Queen Elizabeth House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Anne Residential Home (1) 80 Coombe Lane West Kingston Upon Thames Surrey KT2 7AD Lead Inspector Barry Khabbazi Key Unannounced Inspection 12th June 2007 9:30am X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Anne Residential Home (1) Address 80 Coombe Lane West Kingston Upon Thames Surrey KT2 7AD Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8942 8378 020 8942 3861 gzgorska@aol.com Mrs Krystyna Gordon Post Vacant Care Home 4 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (4) of places Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd August 2006 Brief Description of the Service: Anne Residential Home 1 is a two-storey building set back from a main thoroughfare connecting Kingston and New Malden. Two service user bedrooms are located on the ground floor, the third is located on the first floor and accessed via a set of stairs. There are few amenities within walking distance of the home, but Kingston town centre is a few minutes drive away by car. The home is registered for adults aged over 65 years of age who have Dementia. Staffing of Anne Residential 1 is provided to ensure that, in addition to the manager, there is one staff member per shift on duty at the home. At night, one member of staff sleeps in at the home and is available on-call if needed. Each of the three service users has a call-bell, which can be activated if they require support in the night. The home is a short distance from the owners other care home. There continues to be an emphasis on integration between the service users from the owners other home. The fees are currently £330 to £495 per week. Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key Standards identified throughout this report were assessed at this inspection. This inspection also focussed on following up on previous requirements and recommendations, and any new issues arising. This inspection was unannounced. During this inspection the manager/owner was interviewed. Records, care plans and the building were examined, as were all the residents’ bedrooms. No serious concerns were raised as a result of this inspection. The only current identified areas for improvement were the need to record staff supervision more regularly, to continue to support staff with obtaining their qualifications, and to risk assess the required frequency of testing the water. The home is well run and the care of the residents is maintained to a high standard. This has been consistently confirmed by residents themselves and by the Commission’s communications with relatives. Some comments by residents were: ‘They treat us well here’; ‘I used to visit a friend here and when the time came, I chose to move here myself’; ‘this is a very happy place’; ‘the food is very good’; ‘When I moved I was able to bring my cat with me.’ {See also similar comments from those service users at the sister home, next door but one, in the report for that home, Anne Residential 3}. Some comments received from relatives regarding both homes were ‘Anne residential is excellent in every way, my relative feels safe, comfortable, and happy in this caring, family environment.’ ‘My relative is well looked after and physically she looks better’. ‘The food is very good and staff treat my relative with respect and genuine care’. ‘We make unannounced visits and are always extremely impressed with the level of care our relative receives’. No negative comments have ever been received in any resident or relative questionnaires sent out by the Commission. There have been no care related complaints received by either the home or the Commission. The home provides good consistency of staff. What the service does well: Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 6 This is a home for older people where the residents consistently confirm they experience a caring family like environment. The residents are happy. All the residents have consistently commented that they like living in the home, and like their rooms, meals, staff, and how they are treated. Relatives support this view. Only very positive comments have ever been received from relatives and residents and no care related complaints have been made to the home or the Commission over the last three years of inspection. Friends who visit have also chosen to take up a place at the home. The owner manager is a Dietician and provides meals that are very well balanced nutritionally and contain specific higher areas of nutrition when poor health requires. This has had positive outcomes for the residents’ health and speed of healing, for example in the case of pressure sores. The residents and relatives have confirmed that meals at the home are pleasant and enjoyable. Staff attend hospital with the resident to provide support. The home also brings food to residents when in hospital if the residents’ nutritional needs are threatened by unappetising hospital food. Relatives are welcomed to share meals with their relative at the home and at no charge. Flat screen televisions are supplied to all residents and unusually at no charge. Cable television is available in communal areas and has also been supplied to one resident in their room following a request. Again at no charge. Professional hairdressing is provided, again, unusually at no charge. Residents’ life story books are produced to exercise and maintain memory. Relatives are encouraged to and do maintain contact with the home and other residents including following the death of the resident concerned. It is seen as good practice that the home does not manage any residents’ money and it is to be commended for pursuing alternative solutions. This home is very well maintained and always particularly clean. This has been the case at all announced and unannounced inspections over the last 3 years. What has improved since the last inspection? Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 7 Restraints policies are now readily accessible to ensure that all staff are aware of staff guidance in these areas. The need for window restrictors has been risk assessed to ensure the residents are protected from falling from windows where required. New carpet has been bought for some bedrooms. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3, and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Potential new residents and those making placements are provided with all the information they need to make an informed decision about moving in to the home. The initial assessment now covers all the elements of Standard 3. This will result in more detailed and relevant assessments of a resident’s individual needs and a better understanding of needs by staff. This home does not provide intermediate care with a view to return to the community and Standard 6 is therefore not applicable. EVIDENCE: Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 10 The home has a Statement Of Purpose and a Service User Guide. These are clear and well laid out and currently cover all the elements required under Standard 1. The home uses ‘Standex’ medical assessment forms, which while being comprehensive from a clinical perspective, do not cover any social needs. However other assessment documents are completed in addition to these, {called an initial assessment form} and together they cover all the elements required under Standard 3.3, and in particular a history of falls, oral health, mobility, social interests, religious and cultural needs and carer and family involvement and other social contacts. Standard 6 does not apply to this home as this home does not provide rehabilitation with a view to returning to the community. Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Plans of care are now more holistic and records of the reviews are recorded more frequently . This will help staff know all a resident’s needs and how to meet them. Residents’ personal care needs and physical and emotional health needs are met well by this home. This ensures that the residents’ physical and emotional health is well maintained and therefore the quality of life experienced is also maximised. This standard is currently exceeded. Residents’ medication is also well managed to ensure maximised good health. Residents can be confident they will be treated with dignity and respect. Residents and relatives have commented that they are treated with genuine respect and dignity. The residents’ needs regarding terminal care and following death are met well. Good practice has been identified in treating residents and relatives with respect and sensitivity at times of illness and death. Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 12 EVIDENCE: Evidence of moving a service user on to nursing care sensitively, once the home assessed the resident’s needs have become too medical to be maintained appropriately at the home, was presented. The home uses ‘Standex’ medical Care plan forms, which while being comprehensive from a clinical perspective, do not cover any social needs. However, other documents are completed in addition to these, and together they cover all the elements required under Standard 7. The home has a good record for improving skin viability when a service user starts at the home with a pressure sore, and for preventing pressure sores occurring in the first place. Pressure sore avoidance procedures include 2 nursing beds and air pressure mattresses, hygiene and regular toileting, nutritional and fluid monitoring, healthy and nutritious meals {see also meals}, supplements where required, activities to promote mobility, and a caring and valuing environment. Residents remain registered with their own family General Practitioner whenever it is practicable to do so. The owner stated that a chiropodist visits the home approximately once every six weeks at no charge to service users although private services are also available. Residents are weighed on a monthly basis. Evidence of numerous examples of good practice that together exceed Standard 8, ‘Health’: 1,Residents’ life story books are produced to exercise and maintain memory. 2, Staff attend hospital with the resident to provide support. 3, The home has a good record for improving skin viability when a service user starts at the home with a pressure sore, and for preventing pressure sores occurring in the first place. Pressure sore avoidance procedures include 2 nursing beds and air pressure mattresses, hygiene and regular toileting, nutritional and fluid monitoring, healthy and nutritious meals {see also meals}, supplements where required, activities to promote mobility, and a caring and valuing environment. See also meals, and summary section, what the home does well. Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 13 Medication records were up to date. Medicines are currently stored in a cupboard attached to the wall in each individual’s bedroom. Residents can self medicate subject to a risk assessment. Staff were observed to interact with service users with respect and dignity and demonstrated a good relationship with them. This was confirmed through discussions with residents and relative questionnaires. Personal care needs were addressed promptly, and in a fashion that maintained the respect and dignity of service users. Evidence of good practice presented under Standard 11: . Relatives are encouraged to and do maintain contact with the home and other residents following the death of the resident concerned. Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents feel happy at the home which matches their expectations, preferences and their cultural religious needs. This standard is exceeded. Residents are provided with opportunities to remain part of the local community and are able to take part in appropriate activities. The daily routines and the home’s policies promote the residents’ choice and rights, to ensure equality and that all rights are enjoyed by all residents. This standard is exceeded. Dietary needs are very well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. This standard is exceeded. EVIDENCE: Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 15 The routines of daily living and activities are made as flexible as possible, for example there is no set bed time or getting up time. The home has links with other similar services in the area and residents are encouraged to maintain social contact with their peers through open mornings in the home. Evidence of numerous examples of good practice that together exceed Standard 12: 1, The residents are happy. 2, All the residents have consistently commented that they like living in the home, and like their rooms, meals, staff, and how they are treated. Relatives support this view. Only very positive comments have ever been received from relatives and residents. 3, No care related complaints have been made to the home or the Commission over the last three years of inspection. 4, Friends who visit have also chosen to take up a place at the home. The owner/ registered manager provides transport, if required, to enable residents to undertake visits to places of interest locally. Community interaction includes the local town centre’s resources and shops. Residents are able to attend church should they wish to do so. The owner reported good relationships with neighbours. Individual activities occur and events and birthdays are also celebrated. Residents are encouraged to receive visitors at all times. Evidence of good practice presented under Standard 13: Relatives are welcomed to share meals with their relative at the home and to encourage this further, at no charge. The home is run in a manner that promotes choice and independence and this was confirmed through residents’ comments, policies, and observation. The home does not take responsibility for the control or administration of any residents’ finances. Residents can bring in their own possessions and furniture if they wish and this was observed in their rooms, which had been individualised. Residents can take meals, and particularly snacks, at times and places to suit them and have a choice of meals and alternatives. Evidence of numerous examples of good practice that together exceed Standard 14: 1, Flat screen televisions are supplied to all residents and unusually at no charge. 2, Cable television is available in communal areas and has also been supplied to one resident in their room following a request. Again at no charge. 3, Professional hairdressing is provided, again, unusually at no charge. 4, It is seen as good practice that the home does not manage any residents’ money and it is to be commended for pursuing alternative solutions. 5, One new resident wanted to move in with her cat and this was supported following consultation with the other residents. Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 16 Menus were examined and were nutritiously balanced with at least 5 portions of fruit/vegetables per day and appropriate protein and carbohydrate contents. Many fresh meals are prepared including fresh soup. The owner manager is a Dietician and provides meals that are very well balanced nutritionally and contain specific higher areas of nutrition when poor health requires. This has had positive outcomes for the residents’ health and speed of healing, for example in the case of pressure sores{see Standard 18}. The residents confirmed that meals at the home are pleasant and enjoyable. Evidence of numerous examples of good practice that together exceed Standard 15: 1, The owner manager is a Dietician and provides meals that are very well balanced nutritionally and contain specific higher areas of nutrition when poor health requires. This has had positive outcomes for the residents’ health and speed of healing for example in the case of pressure sores. 2, The residents and relatives have consistently confirmed that meals at the home are of high quality, and are pleasant and enjoyable. 3, The home also brings food to residents when in hospital if the residents’ nutritional needs are threatened by unappetising hospital food. 4, Relatives are welcomed to share meals with their relative at the home and at no charge. Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are managed well which should ensure that residents’ and relatives’ concerns are listened to. The home’s policies and procedures help protect residents from abuse and help staff if they need to tell someone about any bad care practice they may see EVIDENCE: The home has not received any complaints over the last 48 months. No complaints have been received by the Commission over that period. The complaints procedure was clear and contained all the elements required including a written maximum response time of less than 28 days and details of how to contact the Commission. The home has a copy of the local Adult Protection procedure. The home also has a Whistle Blowing Policy and an Abuse Policy. There is a Gifts Policy and the Wills Policy does indicate that staff are precluded from being involved in the making or being the beneficiary of a residents’ will as required under this Standard. The home does not handle any residents’ money and there are lockable spaces in residents’ rooms and a safe for secure holding of valuables. A new Restraints Policy has been created and staff were aware of it and the guidance within it. Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 21, 25, and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is in very good condition externally and internally, and is very well decorated in a homely fashion and very well maintained. This creates a pleasant environment that promotes the residents’ dignity and emotional wellbeing. Facilities are suitable and well maintained and baths have thermostatic mixer valves to prevent scalding. Service users benefit from a safe and comfortable environment. The home is always particularly hygienic and clean, homely and comfortable; this environment therefore promotes a pleasant environment, the residents’ health, and emotional well-being. This standard is exceeded. Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 19 EVIDENCE: The home is in very good condition externally and was well decorated in a homely fashion inside. This home is very well maintained and decorated to a high standard. The baths and showers have been fitted with thermostatic mixer valves to facilitate regulation of the hot water temperature so that it does not exceed 43 degrees Celsius. These are checked regularly and in addition thermometers are used at each use of the bath to double check the temperatures and the results recorded. The environment is safe and risk assessments are available for most potential risks. The last inspection report recorded that the home did not have the bacterial analysis testing results available for inspection. The following requirement was then set: The ‘certificate of bacterial analysis’ testing results are to be sent in to the Commission. Although this has occurred, the manager raised whether there was a need for annual testing. The following new requirement is therefore set to facilitate this: The manager must produce a risk assessment to identify the required frequency of future water testing in relation to the size, usage and age of the water systems. The manager is advised to include the age of the system, and any ‘dead legs’ in her risk assessment. At this unannounced inspection, it was reassuring to see that the home was particularly clean and hygienic. This is an area of good practice commented on by residents during inspections and by relatives in recent surveys. The home has policies covering storage, infection control and dealing with spillages. Hand washing facilities and protective clothing are available where required. Evidence of numerous examples of good practice that together exceed Standard 26: 1,Residents and relatives have been consistent in complimenting the cleanliness of the home. 2, This home is maintained to a high level of cleanliness. 3, The building is always clean and tidy. This has been the case at all announced and unannounced inspection visits. 4,The building is always free of offensive odours. This has been the case at all announced and unannounced inspection visits. Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers are of sufficient quantity to meet the residents’ needs and provide consistency. Although there are staff with the required NVQ 2, and staff currently studying for the NVQ2, this will need to continue to meet the required 50 or more staff with the NVQ2 qualification. Achieving this will raise the quality of staff, their knowledge and their practices. The staff vetting procedure meets the National Minimum Standards fully. This should help protect the residents from undesirable staff. Induction and foundation training to National Training Organisation’s specifications is now in place. This should create a more highly trained workforce. Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 21 EVIDENCE: The home is managed and run on a day-to-day basis by the owner/manager, with assistance provided by staff. In addition to the registered manager’s hours there is a total of 35 care staff hours per week. The owner/manager lives locally and is therefore available in case of emergency. Agency staff are not used. Evidence of good practice presented under Standard 27: 1, The manager and her daughter provide the core staff group and therefore a high level of consistency of known staff on a daily basis. 2, A large pool of staff are rotated to cover the additional hours. These are long serving staff who are all therefore also known to the residents. This has so far removed the need to use agency staff during staff absence, or fill vacant posts with completely new staff. This has had many positive outcomes for the residents as recorded in the summary and throughout this report. For example, only positive comments about the staff have been received from service users and relatives, and the homely atmosphere which is supported by residents not having unknown people in their home. 3, Staff attend hospital to provide support and familiarity to residents. The last inspection report contained the following requirement under Standard 28: 50 of staff must have an NVQ2 qualification. There are now staff with the required NVQ 2 and other staff are currently studying for the NVQ2. This approach should achieve the required 50 . To reflect that the home is now on target to meet the 50 required with its current training programme, the requirement will be replaced with the following: The home must continue with it’s training programme to achieve and maintain 50 or more staff with a NVQ2. All of the staff recruitment records are in place and were available for inspection. At the previous inspections Criminal Record Bureau checks, proof of identity, work permits and references were inspected for all staff and the standard was met. As there had been no new staff since the previous inspection no new records needed to be checked at this time. Please see previous reports for details. Induction and foundation training to National Training Organisation’s specifications is now in place. However most of the existing staff are long term staff. This Standard will therefore need to be assessed once a new staff Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 22 member has been in post long enough to have completed enough of the induction and foundation to enable its effectiveness to be assessed. Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36, and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents benefit from continuity and a well run home and the manager is currently undertaking an additional relevant NVQ 4 qualification. The home has implemented a quality assurance system and an annual development plan, with both involving residents. This should ensure that the home is run in a way that involves the residents and a way that is in the best interests of the residents. Residents’ financial interests are safeguarded by the home’s policies, practice and lack of involvement by the home. This standard is exceeded. Only limited progress has been made with regards to the frequency of recorded staff supervision. This could affect the quality of the work that staff do. Health and safety policies and procedures do generally protect the residents Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 24 EVIDENCE: The owner manager runs the home to a high standard and no management problems have been identified. The owner manager provides consistency and expertise to the residents and has a good relationship with them. The owner manager is a qualified nurse has over 20 years direct experience in the field and is currently undertaking her NVQ4. Quality assurance tools currently include residents and relative questionnaires, discussions, resident meetings, and a complaints system. These quality assurance tools have been pulled together into an internal quality assurance system, which includes this information in the home’s annual plan where appropriate, and then provides a system of feedback and review involving the residents in the form of resident meetings. This should allow open measuring of achievement in improving quality. The home does not hold savings for, or act on behalf of, service users. Evidence of numerous examples of good practice that together exceed Standard 35: 1, It is seen as good practice that the home does not manage any residents’ money and it is to be commended for pursuing alternative solutions. 2, Staff are funded by the home to attend hospital to provide support and familiarity to residents where needed.. 3, Flat screen televisions are supplied to all residents and unusually, at no charge. 4, Cable television is available in communal areas and has also been supplied to a resident in their room following a request. Again at all at no charge. 5, Professional hairdressing is provided, again, unusually at no charge. The last inspection report contained a requirement under Standard 36, for notes of supervision sessions to be recorded and held on individual staff filles. There was evidence of regular supervision happening, but limited reccords of which subjects were covered and how often the supervision occurred. The existing requirement will remain in force until fully met. As this is not a key Standard and is the only requirement in this group of Standards, this requirement will not effect the overall rating of ‘Good’ recorded for this whole group of Standards. All of the health and safety policies and procedures relevant to this Standard have been seen to be present. Fire Safety, First Aid, Food Hygiene, Infection Control, and Handling and Disposal of Clinical Waste policies are all also included in staff induction. Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 25 Control Of Substances Hazardous to Health policies and data sheets were available and these substances were all locked away. All of the procedures and testing of systems required in Standard 38 were also present. See Standard 25 for information regarding water testing. Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x 3 x x x 3 4 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 4 2 x 3 Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP25 Regulation 13(3)4 Requirement Timescale for action 01/12/07 2. OP36 18 (1) 3. OP28 18(1)a The manager must produce a risk assessment to identify the required frequency of future water testing in relation to the size, usage and age of the water systems. Notes of supervision sessions 01/09/07 should be recorded and held on individual staff files. {Timescale of the 01/11/05 not met} The home must continue with it’s 01/12/07 training programme to achieve and maintain 50 or more staff with a NVQ2. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Anne Residential Home (1) DS0000013405.V342517.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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